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1 chicago medical society ThE medical society of cook county concierge medicine Direct Primary Care Gains Momentum page 6 stroke in women July cms welcomes new leader local docs Advance national policies

2 I am ISMIE. Dedicated. Innovative. Committed. Evan S. Oblonsky, MD, Radiologist Policyholder since 2000 As a policyholder, I am proud to know that ISMIE Mutual Insurance Company has protected physicians and our practices for over three decades. They are committed to the physicians of Illinois as our advocates and partners. Founded, owned and managed by physician policyholders, ISMIE works to keep our reputations and livelihoods intact. ISMIE Mutual has continuously insured all specialties throughout Illinois since Policyholders know they can depend on us to remain committed to them not only as their professional liability insurance company, but also as an advocate and partner. Depend on ISMIE for your medical liability protection so you can focus on the reason you became a physician: to provide the best patient care possible. Not an ISMIE Mutual policyholder and interested in obtaining a comparison quote for your medical liability coverage? Contact our Underwriting Division at , ext. 3350, or us at Visit our website at ISMIE Mutual Insurance Company Protecting the practice of medicine in Illinois

3 editorial & art Executive Director Theodore D. Kanellakes art director Thomas Co-Editor/Editorial Elizabeth C. Sidney Co-Editor/Production Scott Warner contributors Bruce Japsen; Abel Kho MD Neelum T. Aggarwal, MD Shyam Prabhakaran, MD James M. Galloway, MD Bechara Choucair, MD Ann Hilton Fisher Mark D. DeBofsky, JD William N. Wewrner, MD, MPH Chicago Medical Society Officers of the Society President Howard Axe, MD President-elect Robert W. Panton, MD Secretary Kenneth G. Busch, MD Treasurer Philip B. Dray, MD Chairman of the Council Kathy M. Tynus, MD Vice-chairman of the Council Adrienne L. Fregia, MD Immediate Past President Thomas M. Anderson, MD Chicago Medicine 515 N. Dearborn St. Chicago IL Chicago Medicine (ISSN ) is published monthly for $20 per year for members; $30 per year for nonmembers, by the Chicago Medical Society, 515 N. Dearborn St. Chicago, Ill Periodicals postage paid at Chicago, Ill. and additional mailing offices. Postmaster: Send address changes to Chicago Medicine, 515 N. Dearborn St., Chicago, IL Telephone: Copyright 2012, Chicago Medicine. All rights reserved. FEATURE 6 Direct Primary Care Gains Momentum Concierge medicine at an affordable cost. By Bruce Japsen president s message 2 Collaboration and Leadership By Howard Axe, MD front office 4 From Hippocrates to HIPAA More security mandates than ever. By Alex Cohn, CISSP, and Abel Kho, MD, MS Academic medicine 8 Stroke in Women By Neelum Aggarwal, MD, and Shyam Prabhakaran, MD public health 10 CMS Joins Leadership of Building a Healthier Chicago By James M. Galloway, MD 11 Chicago s Top 12 Public Health Priorities By Bechara Choucair, MD legal 13 Unintended Disclosure of HIV+ By Ann Hilton Fisher, JD 14 A Brief Guide to Disability Insurance By Mark D. DeBofsky, JD Legislative Advocacy 16 ISMS Protects Physicians from Bad Bills By William N. Werner, MD, MPH member benefits 17 Service of the Month CMS Career Center and Job Board 18 A New Twist on Stroke Treatment 22 Society Welcomes New Leader 26 CMS Annual Awards News & Events 28 Chicago a Leader in Innovative Care 31 Calendar of Events who s who 6 Volume 115 Issue 7 July It s All About Doctor-Patient Academic leader tells what s most important July

4 MeSSAGe FroM the PreSIDeNt collaboration and leadership As practicing physicians, we care for patients on a daily basis. As a primary care physician, I regularly collaborate with my specialist colleagues to diagnose and treat my patients varied ailments. By phone, on the hospital unit, or consult report, we work together to form a treatment plan that best suits patients and their problems. Often, I find face-to-face conversation the best way to exchange ideas and share input. This experience also plays out as the Chicago Medical Society increases efforts to reach out, collaborate, and build relationships. Listening to what our members told us over the past year, we consulted and formed a plan for better engaging and serving physicians in Cook County. Highlights include: howard Axe, md, was installed as the 164th president of the chicago medical society in ceremonies on June 12. see page 22 for coverage. Our Governing Council s modified format welcomes physicians from academic institutions and other groups, so we can hear how to best meet the needs of diverse groups, while stimulating their participation. The Society recognizes that academic doctors have different needs than employed physicians, whose needs are different than those of independent physicians practicing in small groups. On the District level, we are creating meaningful programs and services. Our reinvigorated committee structure allows more opinions to be heard and policy formulated that reflects our organization s diversity. In building broad-based coalitions with those who share our interests, we can more effectively institute meaningful change in the healthcare system. Our advancement from supporter to partner in the Building a Healthier Chicago initiative demonstrates our expanded role in the public health sector. Our role in an Institute of Medicine of Chicago forum highlighted the activities and positions of our Society. Thomas M. Anderson, Immediate Past President, represented you. In a Chicago Public Schools program, Anne Szpindor, MD, and I educated physical education teachers on asthma and diabetes. The Society teamed with the American Bar Association s Health Law Section to hold an educational conference. Yes, I was also skeptical initially, but have come to appreciate the value such a working relationship can provide to both organizations. Our Mini-internship Program continues to pair a legislator with a practicing physician to see firsthand how medical care is delivered. Through this program we are promoting Chicago s 22 Primary Stroke Centers (PSC). The PSCs offer the full spectrum of services to those suspected of suffering a stroke. Productive partnerships are increasingly vital as our country s healthcare landscape evolves, along with the way care is provided. These relationships will require our members active participation, and our finding common ground. Listening and valuing the contributions and approaches of others are both critical to providing patient-centered, high-value care to patients and their families. I urge you to join these efforts. You will find membership professionally and personally rewarding, as we channel our energies in a positive direction. Please send me your comments and suggestions for strengthening your Society. 2 Chicago Medicine July howard Axe, md President, Chicago Medical Society

5 When it comes to Meaningful Use, athenahealth did all the legwork and then they made it easy for me to do. Dr. Reavis Eubanks This is how Dr. Eubanks got paid for Meaningful Use. After practicing medicine 35 years, Dr. Reavis Eubanks knew it was time for an EHR. As a solo physician, he needed an easy transition and an effective way to begin earning up to $44,000 in Medicare incentive payments. athenahealth helped Dr. Eubanks go from paper to payment in just six months. With guidance every step of the way and proven, cloud-based services. Best in KLAS EHR * Seamless clinical workflow Free coaching and attestation Guaranteed Medicare payments ** 85% of eligible athenhealth providers attested to Stage 1 Meaningful Use. And we re ready for Stage 2. Visit or call *ambulatory segment for practices with physicians ** If you don t receive the Federal Stimulus reimbursement dollars for the first year you qualify, we will credit you 100% of your EHR service fees for up to six months until you do. This offer applies to HITECH Act Medicare reimbursement payments only. Additional terms, conditions, and limitations apply. Cloud-based practice management, EHR and care coordination services

6 front office From Hippocrates to HIPAA More security mandates than ever by Alex Cohn, CISSP, and Abel Kho MD, MS Above all, create a record of what you ve done. Just as you record information on patients as part of the medico-legal record, be sure to keep documentation (receipts, policies, assessment results) for any possible future audit, however unlikely at this time. You may not think you learned about privacy and security in medical school, but you did. It s right there in the Hippocratic Oath: What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account must be spread abroad, I will keep to myself, holding such things shameful to be spoken about. The principles captured by the Hippocratic Oath still apply, but how we maintain the privacy of our patients records in a digital age continues to evolve. Understanding new technologies and complex federal regulations requires significant time and effort outside the scope of our practice of medicine. Did we mention the regulations? The Health Insurance Portability and Accountability Act of 1996 (HIPAA) set federal standards for the protection of individually identifiable health information. A privacy and security risk assessment is a required component for achieving meaningful use of an electronic health record (EHR) if you re participating in the Medicare or Medicaid EHR Incentive Program. The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 further requires that breaches of protected health information affecting more than 500 individuals be publicly posted. Indeed, there are more privacy and security mandates for physicians to keep track of than ever before. Audits will Increase Next Year A recent search of the Department of Health and Human Services Website yields more than 400 recorded breaches by hospitals and clinics. In Arizona, a cardiac surgery practice was fined $100,000 and required to implement a corrective action plan for such a breach. Over the past year, the professional services firm KPMG conducted 100 random audits of eligible providers to assess their adherence to the federal privacy and security standards. The number of audits is expected to increase in This all may sound burdensome, but we all know it s for the best. And with a few key steps, you can ensure protection for yourself, your practice and your patients: First, consider some simple security measures. Make sure you are using strong passwords that are longer than eight characters; contain no dictionary words; and include a mix of letters, numbers and special characters. Never share your username or password with anyone, even your staff. Install anti-virus software on all of your desktops, laptops, tablets and servers. Install a firewall between your practice and the Internet, to keep prying eyes out of your data. Encrypt all of your laptops and mobile devices that contain patient data. Ensure you have appropriate physical locks in place and fire protection for your medical records. Start with Security Risk Analysis Perform a security risk analysis. These measures are a good start for protecting your data; however, to fully protect your practice as well as comply with federal regulations like HIPAA, you will need to perform a security risk analysis. This is a formal process that starts with a detailed inventory of your practice, including all staff, hardware and systems that deal with patient data. Next, you will put together a comprehensive list of all the threats and vulnerabilities to the staff, hardware, and systems you just identified. Then you evaluate each of these threats and vulnerabilities to determine their level of risk. Once you have determined that risk, you re ready to make a list of controls to mitigate those risks and sum up the analysis. Above all, create a record of what you ve done. Just as you record information on patients as part of the medico-legal record, be sure to keep documentation (receipts, policies, assessment results) for any possible future audit, however unlikely at this time. If this all sounds a bit too far afield, seek professional assistance. As Chicago s federally funded resource for health IT assistance, we have helped train seven local information systems consulting firms to conduct formal privacy and security risk assessments. We have a complete set of tools and checklists, as well as a list of trained IT consultants, available to help guide you. For recorded Webinars and additional information, visit us at: Dr. Kho is an internist and co-executive director of the Chicago Health IT Regional Extension Center (www. CHITREC is federally funded to directly assist providers in Chicago achieve meaningful use of electronic health records. Alex Cohn is CHITREC s privacy and security officer. 4 Chicago Medicine July 201 2


8 Direct Primary Care Gains Momentum Concierge medicine at an affordable cost By Bruce Japsen For the daily cost of a Grande Starbucks latte, more primary care doctors like Anthony Auriemma, MD, say they are pretty confident they can provide their patients high-quality medical care at an affordable price and ultimately save the healthcare system a lot of money. The 35-year-old family physician practices in the western suburbs of Chicago and is part of a growing number of doctors who are offering what they hope is a more affordable approach to concierge medicine known as direct primary care. Unlike concierge care for wealthy people, which sparked a 2005 investigation by Congress investigative arm, the Government Accountability Office, the new direct primary care approach generally runs between $50 and $100 a month with lower prices for children. Those prices are in contrast to what worried some lawmakers who saw patients losing access to medical care if they could not afford membership fees of $5,000 to $15,000 a year or more that 6 Chicago Medicine July were outlined in the GAO report. Doctors say they can still care for most primary care needs and do it without the interference of an insurance company, for as little as $50 a month in many cases. The nice thing about this model is that I know my patients because I have 400 to 600 patients, whereas in the typical primary care model, a doctor has 2,000 to 3,000 patients, Dr. Auriemma said. It s trying to put customer service into medicine, which has been missing. Unlike the concierge practices that gained a lot of attention a decade ago, direct primary care practices say they provide more than just convenience, but a way to keep costs low because they keep patients from unnecessary and expensive trips to the hospital emergency room. They do this by giving patients an overthe-phone diagnosis that may only require a prescription or treating the ailment in the clinic when possible and avoiding an unnecessary referral. For $125 a month, Dr. Auriemma provides all the primary care a patient needs through unlimited office visits as well as round-the-clock mobile phone access and consultations. Dr. Auriemma said he is able to offer a lower priced, $50-a-month option and provide the same service though patients insurance, which would be billed for traditional primary care services including tests and visits. If patients need more specialized care or hospitalizations, they generally purchase a high-deductible plan, Dr. Auriemma and direct primary care advocates say. The direct primary care approach is catching a wave of attention across the country, drawing major investors and convincing state policymakers to change rules to allow the concept to flourish. Several companies have launched across the country to back doctors who want to join direct primary care practices, drawing some large Wall Street investors or big names like online retailer Amazon founder Jeff Bezos, who has helped back the expansion of Seattle-based Qliance. Supporters say the easier access to a physician and the ability to call or any time with questions or advice potentially keeps a patient out of the more expensive hospital setting or away from an unnecessary and expensive emergency room visit. Currently, in most primary care practices, there is no reward for seeing a patient on time, listening to their needs, curing their ills, or cultivating compassion and trust, said Dr. Garrison Bliss, Executive Vice President of Medical Affairs at Qliance, a direct primary care practice that charges $59 a month for services that include sameday or next-day appointments, unlimited visits and 24-hour access to a physician via or telephone.

9 DIRECT PRIMARY CARE With direct primary care these elements become central to the overall success of a practice, because if patients are unhappy they can go elsewhere. Bliss is also a co-founder of the Direct Primary Care Coalition, which was formed in part to promote the healthcare model and to convince members of Congress that it could be a solution or at least help rein in federal health spending, particularly for the more than 48 million Americans covered by Medicare. Though direct primary care practices involve only a fraction of practicing physicians today, they are growing. The coalition estimates there are direct primary care practices in two dozen states that are treating more than 100,000 patients. Direct primary care practices say they are beginning to interest more employers in their concept, which will allow them to charge fees lower than $60 if they get a higher volume of patients. Qliance, for example, charges someone who pays outof-pocket such as an uninsured person, a monthly membership fee of between $49 and $89, depending on age. An older person with more needs might pay more. Employers are drawn in by pitches from the practices that say administrative overhead and bureaucracy adds 20% or more to costs by some estimates. Washington State s largest employee union plan this year offered a direct primary care option from Qliance that lowered employee-only premiums for the United Food & Commercial Workers Local 21 to $5 a week from $9 a week. The union said it purchased Qliance after first conducting a pilot program with the direct primary practice to see if it worked and would, indeed, lower costs. Through our pilot program, we were able to see how Qliance can bring down overall healthcare expenditures and keep our members healthier, Diane Zahn, Secretary of the South Health & Wellness Trust, and Secretary-Treasurer of UFCW Local 21, said at the time the broader relationship was announced last November. But not all areas of the country are as welcoming of direct primary care, and Illinois may need the blessing of the state insurance director before broader usage of direct primary care can happen here. In most states, insurance directors at first glance consider certain direct primary care practices as prepaid health plans, which means they would require millions of dollars in capitalization. If I am paying a provider a fixed monthly amount to receive unlimited physician visits, I believe that our law would call that pre-paid health or capitated care, said David Grant, Deputy Director of the Health Products Division for the Illinois Department of Insurance. Provider groups would be found to be bearing risk and would need to be appropriately licensed. States have, however, been making changes to their insurance rules to allow more direct primary care, saying this care is different than capitated HMO-style care because it doesn t restrict care to a network and it provides unlimited access without co-payments. Washington State legislation was passed in recent years to allow more direct primary care practices to operate free of such insurance rules. Several other states, including California, have worked with insurance directors to allow for more direct primary care or are working on legislation to allow it. We have to educate on what direct primary care practices are, said Jay Keese, principal with Capitol Advocates, a Washington lobbying firm that is representing the Direct Primary Care Coalition. On the federal level, Keese and the Coalition have helped lead a legislative effort that so far has bipartisan support in Congress. It was introduced by Rep. Bill Cassidy, a Louisiana Republican, and U.S. Rep Jay Inslee, a Democrat. (Inslee resigned his seat earlier this year to focus on his campaign for Washington governor.) A U.S. House bill introduced late last year would create pilot programs for Medicare beneficiaries as well as people enrolled in both Medicare and state Medicaid programs who are known as dual eligibles. Under the proposed Direct MD Care Act, monthly fees could not exceed $100 for Medicare beneficiaries. Without the law, doctors who contract directly with patients say they cannot treat Medicare patients because doctors cannot bill for services Medicare already pays doctors for. The Act says that direct primary care medical homes in the pilot projects will provide Medicare patients and dual-eligible patients with the following: preventive care; wellness counseling; primary care that is coordinated with specialized and hospital care; urgent care services; office appointments seven days a week, and telephone consultations; and 24-hour access to urgent care consultations by telephone any day of the week. Supporters say the legislation s emphasis on lower-cost primary care is key, particularly when members of Congress are under pressure to control spending. This kind of care should be a centerpiece of healthcare policy, not only because it will be a nice thing for doctors and patients, but also because it dramatically reduces overall healthcare costs in the private sector by keeping people healthier, thereby reducing ER visits, hospitalization days, surgeries and specialist visits by remarkable numbers, Dr. Bliss said. If passed, this bill would enable the Centers for Medicare and Medicaid Services to measure the downstream costsavings and health benefits of providing Medicare and Medicaid beneficiaries with unrestricted access to direct primary care, and could significantly reduce the cost of caring for America s sickest and poorest population by providing easy access to high-quality primary care. Though the developers of direct primary care practices say their model saves money and they have their own internal data showing that, supporters and skeptics alike acknowledge the Medicare pilot projects would also test whether money can be saved in the government program. Physicians like Dr. Auriemma believe the potential for savings is an achievable goal. If you can communicate regularly with patients with diabetes, you can save money on doctor visits, hospital visits, or adverse events from medications, Dr. Auriemma said. The average patient sees the doctor about three times a year but for people who have diabetes, hypertension or other chronic conditions, telephone follow-up will help them and also save money. If we can improve cost efficiencies and outcomes, there is no reason not to give it a try. Bruce Japsen is an independent Chicago healthcare journalist and a contributor to the New York Times and writer for the Times Prescriptions healthcare business and policy news blog. He was healthcare business reporter at the Chicago Tribune for 13 years and is a regular television analyst for WTTW s Chicago Tonight, CBS WBBM radio 780-AM and FM and WLS-News and Talk, 890-AM. He teaches healthcare writing at Loyola University Chicago and has taught in the University of Chicago s Graham School of General Studies medical editing and publishing certificate program. He can be reached at July

10 academic medicine stroke in Women Second leading cause of death by Neelum T. Aggarwal, MD, and Shyam Prabhakaran, MD on AVerAge, every 40 seconds someone in the U.S. has a stroke, the nation s leading cause of disability and the fourth leading cause of death. In women, stroke is the second leading cause of death, with 425,000 women suffering from stroke each year, 55,000 more than men. Not only is the overall stroke rate higher for women than for men, women are more likely to have more disability and poorer outcomes than men. Women s symptoms more Atypical What are the possible reasons to explain this observation? One study showed that women may experience longer delay from arrival to emergency rooms to the time they are evaluated for stroke symptoms. The delay may be due to possible gender differences in the reporting of acute stroke symptoms. In a study of 1,189 admissions that ended with a confirmed stroke diagnosis in the emergency room, traditional stroke symptoms of postural imbalance (men 20% vs. 15% in women) and hemiparesis (men 24% vs. 19% in women) were more likely to be the presenting symptoms for men than for women. In addition, women were more likely to present with symptoms that were more atypical for stroke, including pain, and Primary Stroke centers THe CHiCAgo AreA is now home to 22 primary stroke centers that provide state-of-the-art clinical care 24/7 to prevent stroke, minimize disability in stroke survivors, and ensure the best possible outcomes for patients following a stroke. please refer to this listing of pscs. adventist hinsdale hospital advocate christ medical center advocate good samaritan hospital advocate illinois masonic medical center advocate lutheran general hospital advocate south suburban hospital advocate trinity hospital alexian brothers medical center ingalls memorial hospital John h. stroger, Jr., hospital of cook county little company of mary hospital loyola university medical center macneal hospital mercy hospital and medical center mount sinai hospital medical center northshore university healthsystem northwestern memorial hospital our lady of the resurrection medical center resurrection medical center rush university medical center saint alexius medical center saint francis hospital saint Joseph hospital saints mary and elizabeth medical center university of chicago medical center university of illinois medical center at chicago west suburban medical center westlake hospital change in cognition or level of consciousness. Another possible reason centers around the type of medical treatment given after the diagnosis of stroke is made. Studies have shown that once a diagnosis of stroke has been made, the type of treatment given to women and men differ. In fact, the gender differences in management of stroke appear to be similar to the well-documented gender differences noted in the treatment of cardiac disease; where women are less likely to receive major diagnostic and therapeutic procedures. Differences may also exist in medical treatment for stroke prevention. Men with stroke are more likely to have significant co-morbidities, such as higher rates of ischemia, heart disease, and diabetes compared to women, who have higher rates of hypertension and atrial fibrillation. This cardiovascular medical history profile noted in men may result in more aggressive preventative treatment in men than in women. Carotid disease more Common in men Aspirin and warfarin are equally effective medications for stroke prevention in men and women. Carotid endarterectomy (CEA) is another important treatment for the primary and secondary prevention of stroke in patients with significant carotid stenosis. Although carotid disease is more common in men than women, some studies have shown a higher rate of post-operative complications in women, such as post-operative stroke. Other studies have found no differences in morbidity and mortality. Commonly cited complication rates in women have been old age at time of presentation for CEA, presence of hypertension, and smaller size carotid arteries. Hypertension more Common in Women In stroke and heart disease, the commonly recognized risk factors of smoking, elevated cholesterol, a previous stroke, and large artery atherosclerotic disease, hold true for both men and women. Workup following new stroke should be similar in both sexes. Hypertension and elevated cholesterol are more common in women as they age. Typically, cholesterol levels will increase at the age of 45, presumably due to the onset of menopause. For women who are pre-menopausal, the stroke rate is low except when associated with hormonal contraception. Pregnancy does not appear to increase stroke rates significantly until the last trimester, although pregnancy can complicate pre-existing cerebrovascular disease. Specific differences, though, have been found in some risk factors for women that may predispose them to stroke. One study found that women with stroke had an elevated tissue plasminogen activator antigen, which was an independent risk factor for stroke in non-diabetic women ages 15 to 44 yearsold. Other studies have shown that a significant proportion of young women have elevated homocysteine serum levels, an independent risk factor for stroke and vascular disease. Serum homocysteine levels were decreased in women who took daily multivitamins with B6, B12, and folate. Last, oral hormone replacement used by menopausal women may increase the stroke rate. Dr. Aggarwal is a cognitive neurologist at Rush University Medical Center, and the clinical core co-leader of the NIA-funded Rush Alzheimer s Disease Research Center. Dr. Prabhakaran is a stroke neurologist, and head of the section of cerebrovascular diseases and neuro-critical care at Rush. 8 Chicago Medicine July 201 2

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12 public health Cms Joins leadership of Building a Healthier Chicago there is no cost to becoming a stakeholder by James M. Galloway, MD We seek dedicated individuals who are willing to commit their expertise to improve the health of Chicago residents. We Are proud to welcome the Chicago Medical Society to Building a Healthier Chicago s (BHC) executive leadership team. Since 1850, your renowned organization has led important public health initiatives in the city, mobilizing thousands of dedicated physicians to combat disease and poor sanitary conditions, among other threats. The Society s participation on the leadership team will help BHC further align and synergize coalition efforts throughout our communities. Team members also include the U.S. Department of Health and Human Services (Region V), Chicago Department of Public Health, and the Institute of Medicine of Chicago. BHC was initiated four years ago to work with hundreds of local and national stakeholders, uniting and supporting organizations, businesses, and non-profits around the goals of prevention and healthy living. Our synergies and relationships continue to grow stronger, larger, and more effective. Team efforts are focused primarily in three general areas: Improvements in healthy eating Increased physical activity levels The prevention, detection, and control high blood pressure We work with community organizations, academics, healthcare and governmental bodies, promoting a wide range of events, interventions, policy and system changes, and partnerships so every individual can access information, resources, and support for a healthy lifestyle. Not only that, BHC promotes and tracks the adoption of selected programs, practices, policies, and supportive environments throughout worksites, schools, healthcare organizations, faithbased organizations, parks and neighborhoods of Chicago. There is no cost to become a BHC stakeholder. We facilitate joint projects among our stakeholders, information sharing and collaborative learning, and training, building a comprehensive network of programs and services. Now is the time to join our growing network. We seek dedicated individuals who are willing to commit their time, energy, expertise, and resources to effectively improve the health of Chicago residents through this meaningful collaborative approach. Working together, we can provide Chicagoans healthy alternatives where they live, learn, work, eat, play, and pray. Learn more about Building a Healthier Chicago by going to: Dr. Galloway is Assistant U.S. Surgeon General and Acting Regional Director, Regional Health Administrator, Region V (Illinois, Indiana, Minnesota, Ohio, Wisconsin). In addition, he is also adjunct professor of medicine at Northwestern University s Feinberg School of Medicine in the departments of cardiology and preventive medicine. He can be reached at: first Surgeon General had Local Roots CHiCAgo is Home of the first u.s. surgeon general, John maynard woodworth. a graduate of the chicago medical college in 1862, dr. woodworth became a demonstrator in anatomy at the college in he was also appointed as surgeon of the soldier s home of chicago and sanitary inspector of the chicago board of health in that same year. in 1871, dr. woodworth was appointed as the first supervising surgeon of the marine hospital service, based in washington, dc. the title was changed in later years to surgeon general. 10 Chicago Medicine July 201 2

13 public health Chicago s Top 12 Public Health Priorities Responding to challenges since 1835 by Bechara Choucair, MD Healthy Chicago s 12 discrete priority areas for action. Beginning with the 1835 cholera outbreak, the Chicago Department of Public Health (CDPH) has responded to health challenges impacting our residents and city. In keeping with that mission, the CDPH launched the city s first public health agenda, Healthy Chicago, last year. This action plan outlines the city s top 12 public health priorities, with more than 193 strategies to achieve measureable targets over the next five years. Each priority area focuses on creating new policies to improve public health; delivering new programs and services; and leading educational and public awareness campaigns. These combined efforts will lead to a healthier city for residents in every neighborhood. Working with community partners, we are already creating more smoke-free places to reduce residents exposure to secondhand smoke; designating hospitals as Baby Friendly to encourage new moms to breastfeed; and introducing mobile produce carts that give residents access to fresh fruit and vegetables as one strategy to lower obesity in our city. Improvements in our city s health require more than a response from local health departments and lawmakers. Physicians are encouraged to get involved. Please view our full agenda online at and give us your feedback on key strategies to transform the health of our city. Suggestions should also come from faithbased organizations, educational institutions, community groups and individuals. Chicago Medical Society members can follow the progress of Healthy Chicago by downloading monthly updates from the CDPH website or by signing up to receive updates at com/6pu9d96. You can also find us on Facebook (ChicagoPublicHealth) and Dr. Choucair is Commissioner of the Chicago Department of Public Health. Please contact him at choucair on Twitter. July

14 public health The View from Our Office Million Hearts national initiative needs you by James M. Galloway, MD We, as physicians, can help prevent one million heart attacks by 2017, says Dr. James Galloway, Assistant U.S. Surgeon General and Regional Health Administrator, Region V, U.S. Public Health Service. As a cardiologist, my primary focus and passion has long been the prevention of cardiovascular disease in our nation. I would like to share an exciting and vitally important public-private initiative with significant potential to save lives and prevent disease. We all are aware that CVD is the leading cause of death in the U.S., with more than two million strokes or heart attacks annually and more than 800,000 deaths. In fact, one in every three Americans dies of heart disease and stroke roughly 2,200 deaths per day and 92 individuals per hour! From an economic perspective, CVD care accounts for one out of every six dollars in healthcare expenditures, costing our nation $444 billion annually in medical care and lost productivity. Mediated in part by a massive increase in obesity and associated risk factors, these rates are expected to triple nationally in the next two decades if the trend is not effectively addressed. The great news is that we, as physicians, in addition to our roles as medical and public health leaders in the Chicago area, can lead efforts to prevent these killers of our patients. Million Hearts is a bold national initiative that focuses many existing prevention efforts on an audacious but achievable goal: preventing one million heart attacks and strokes by It is time for us to take the next big step and bring this goal to fruition. In the Chicago area alone that equates to CVD events among roughly 28,000 friends, colleagues and fellow citizens. The prevention of one million heart attacks and strokes by reducing risk factors for CVD is an enormous task, one which requires coordination and alignment of efforts by both clinical and community-based organizations, as well as individual efforts. In the clinical realm, Million Hearts focuses on managing the ABCS aspirin for high-risk patients; blood-pressure control; cholesterol management; and smoking cessation. There is also an associated community-based prevention effort to reduce smoking, improve nutrition, and reduce high blood pressure. Currently, only 47% of people with ischemic heart disease take daily aspirin or another antiplatelet agent; only 46% of patients we diagnose with hypertension have it adequately treated; only one-third of our patients with hyperlipidemia have achieved appropriate control; and less than one quarter of smokers who try to quit get counseling or medications. As a result, more than 100 million people half of American adults smoke or have uncontrolled high blood pressure or elevated cholesterol levels; and many have more than one of these cardiovascular risk factors. Increasing utilization of simple clinical interventions alone and monitoring our efforts could save more than 100,000 lives a year. To get involved, visit our website at: www. Together, we can save a million hearts and many more. Dr. Galloway is Assistant U.S. Surgeon General and Regional Health Administrator, Region V, U.S. Public Health Service. The opinions expressed in this article are those of the author and do not necessarily reflect the views of the Office of the U.S. Department of Health and Human Services or the federal government. 12 Chicago Medicine July 201 2

15 legal Unintended Disclosure of HIV+ Statutory penalties and other damages by Ann Hilton Fisher, JD HIV remains a uniquely stigmatizing disease despite concerted efforts to make HIV testing and care routine. Associations with illicit drug use and homosexuality, uncertainties about the origins and modes of transmission, and vivid recollections of the days when a diagnosis almost always meant a death sentence, have combined to create high levels of fear throughout society. As recently as 2009, a national study by the Kaiser Family Foundation found that 35% of respondents would feel uncomfortable having their child taught by an HIV+ teacher and 51% would feel uncomfortable eating a meal prepared by someone with HIV. This stigma is often internalized by people with HIV, making people reluctant to seek treatment for this life-threatening illness. Because stigma is so pervasive, public health officials have always worked to assure people with HIV and those at risk for HIV that their status will be kept strictly confidential. In Illinois, HIV confidentiality is governed primarily by the Illinois AIDS Confidentiality Act (410 ILCS 305/2). The AIDS Confidentiality Act predates HIPAA. It is more protective of patient confidentiality than HIPAA, so it controls in cases where the two statutes may come in conflict. There are three areas in particular that frequently come up in healthcare settings. Incidental Disclosures. Every few weeks someone calls the AIDS Legal Council of Chicago to complain that a healthcare provider disclosed their HIV status to someone who was visiting their hospital room or accompanied them to an emergency room. It may be an anesthesiologist coming in the evening before surgery and mentioning that it will be all right if they take their HIV medications in the morning. Or an emergency room doctor accessing the chart of someone who came in after being injured in a baseball game and asking, in front of the teammate who accompanied the patient to the ER, Are you taking your HIV meds? Although these incidental disclosures might be permissible under HIPAA, as long as the facility and individuals took reasonable safeguards to protect confidentiality, the AIDS Confidentiality Act has no similar exemption. A disclosure of someone s HIV status to a third party is prohibited absent a legally effective release. Regulations specify that a legally effective release must be in writing. The best practice in this situation is to always ask visitors to leave the room before any discussion of HIV takes place. If the patient indicates that the visitors are aware of his or her status and the patient would like them to participate in the conversation, have the patient sign a release to that effect, which can then be placed in the patient s chart. Duty to Warn. Healthcare providers frequently ask whether they can or must warn the sexual partners of their HIV-positive patients that they are at risk of contracting HIV. HIPAA provides that covered entities can disclose to a person who may have been exposed to if the covered entity is authorized by law to notify such person (45 CFR (b)(1)(iv). The Illinois AIDS Confidentiality Act allows, but does not require, physicians (but not other healthcare providers) to tell the spouse or partner in a legal civil union of their HIV+ patient, but only after first trying to persuade the patient to tell the spouse or partner themselves. The law specifically states that it creates no duty to warn and that physicians acting in good faith are protected whether or not they warn the spouse or partner. The law does not permit disclosure to any other partners. Damages. HIPPA allows no private right of action, instead placing the enforcement responsibility on the HHS Office of Civil Rights and the Department of Justice. Individuals may file complaints, but there is no assurance they will be investigated, and even where serious violations are found that lead to civil monetary penalties, the individual patient is not awarded damages. In contrast, the AIDS Confidentiality Act explicitly provides not only a right to sue for violations of the Act but also statutory penalties for violations. Because these are statutory penalties, the person does not have to prove actual damages. Individuals who do have actual harm can receive more than the statutory damages. The minimum penalty for a negligent violation (such as the overheard bedside conversations discussed above) is $2,000 per violation. The minimum penalty for a reckless or intentional violation is $10,000. The law also allows for injunctive relief and attorney s fees. Healthcare providers with a question about HIV disclosure should consult their own risk management staff. But the AIDS Legal Council of Chicago is also available to provide training and respond to questions from service providers. Council staff can be contacted at The author is Executive Director of the AIDS Legal Council of Chicago. Every few weeks someone calls the AIDS Legal Council of Chicago to complain that a healthcare provider disclosed their HIV status to someone who was visiting their hospital room. July

16 legal A Brief Guide to Disability Insurance Various factors can work in a claimant s favor by Mark D. DeBofsky, JD The most desirable coverage is individual disability insurance that pays a fixed monthly benefit and insures against the inability to perform the key duties of one s occupation. Introduction Filling out forms for disability claims can be the bane of a doctor s existence. Besides being timeconsuming to complete, doctors are requested to specify functional limitations that are often impossible to measure. Indeed, the entire concept of disability is elusive, since a disability determination involves a combination of legal, vocational and medical considerations. The following brief discussion is intended to help physicians better understand how disability insurance works. Disability Insurance and Social Security Disability Benefits Obtaining Social Security disability benefits can be the most difficult since the entitlement to benefits requires a complete inability to work. However, various factors can work in a claimant s favor. In addition to objective medical test results and clinical findings, Social Security evaluates the impact of pain and other symptoms, as well as the co-morbidity of multiple impairments. Vocational factors such as the claimant s age, education, and skill level are also taken into consideration. Since it is difficult to qualify for Social Security disability benefits, and because benefits are capped at approximately $2,500 per month for the highest wage earners, many professionals such as physicians purchase private disability insurance. The most desirable coverage is individual disability insurance that pays a fixed monthly benefit and insures against the inability to perform the key duties of one s occupation, or even a specialty within that occupation. Benefits may be also payable for partial disabilities or even a loss of income following a recovery from illness or injury. It is also possible to purchase insurance to cover fixed business overhead costs in the event of disability. When premiums for individual coverage are paid with after-tax dollars, the benefits are not subject to federal income taxation. In contrast to individual disability insurance, many organizations purchase group disability insurance for their members and employees. Those benefits typically represent a percentage of salary and are more likely to be taxable. Group disability benefits are also generally subject to offsets, which include Social Security disability payments (both for the insured and their dependents) as well as other group coverage, which may include disability insurance purchased through a medical association. Thus, instead of a supplement, such coverage may prove worthless if those payments reduce the amount of group disability insurance benefits. Group coverage is also not necessarily focused on the insured s occupation or specialty most policies apply a more generalized definition of disability after an initial benefit period. In addition, group coverage is more likely to include provisions that limit the duration of benefit payments for certain specified conditions such as psychiatric disorders or other illnesses deemed self-reported such as migraine headaches, fibromyalgia, and chronic fatigue syndrome. Finally, group coverage is usually subject to the Employee Retirement Income Security Act (ERISA). The applicability of ERISA limits both judicial remedies and court procedures, giving greater advantages to insurers in the event of a dispute over benefits. Disability Determinations The determination of disability involves three components a contractual or statutory definition of disability, medical findings pertaining to diagnosis as well as physical and other restrictions and limitations, and a vocational analysis focused on whether the established limitations preclude employment either in a particular job or generally. Although the Social Security Administration gives limited deference to treating doctor opinions, neither the Social Security Administration nor any insurance company will accept a doctor s opinion that the patient is disabled without a description of specific physical, cognitive, or other restrictions and limitations supporting that conclusion. Nor do private insurers afford deference to treating doctor opinions; many also now eschew independent medical examinations in favor of record reviews, often without obtaining any input from the treating doctor. Beware of the myth of the functional capacity evaluation (FCE) as an objective means of assessing disability since none of the test protocols have been validated by rigorous scientific study. While the results of FCE testing may be useful in corroborating treating doctor opinions, it is difficult to extrapolate someone s ability to work on a full-time basis from only a few hours of testing and observation. Conclusion More than eight million Americans receive Social Security disability benefits, and many more receive disability insurance. Protecting one s earnings by insuring against unforeseen illness or injury is critical. Those deserving of compensation need the support of their doctors along with experienced legal representation. Even those in good health and in the prime of their careers cannot ignore the risk of disability and should review the adequacy of their own disability protection. Mr. DeBofsky practices in the Chicago law firm of Daley, DeBofsky & Bryant. 14 Chicago Medicine July 201 2

17 member benefits enemies no more cms launches new partnership with the legal community in THe PAsT year, the Chicago Medical Society initiated a mutually beneficial new relationship with the Health Law Section of the American Bar Association. As the article on page 32 shows, our first joint effort was a Physician-Legal Issues conference featuring both physicians and attorneys as presenters and audience members. Participants came away with new insight and information about medical practice options available under healthcare reform. In addition to providing our members with guidance on navigating the healthcare landscape, the partnership helps to bring together two professions with shared professional and personal interests. We say shared because the massive shifts in our heavily regulated healthcare system mean that doctor-lawyer alliances are crucial to steering the course and protecting physicians rights and interests. In spite of their historic antagonism, the 40 4RM 4MK 4K' 4's 4s0s RMK's 0d0dy0yn0na0am0mi0ic 0c 0in 0nt 0te 0eg 0gr 0ra 0a dynamic integrated solutions are 4es 4si 4ig 4gn 4ne 4ed 4d0d d4de designed 0fo 0or 0rm 0m 0yo d t0to0o to t0tr0ra0an0ns0sf transform your results quickly. In 4ac 4ct 4t, 4, 4yo 4ou 4u0b 4u0u 4c0c f4fa fact, you 0e 0yo 0ou 0ur 0r c0co0ou0ul0ld0d could see s0se0ee your bottom line improve 4b0b 0to 0o 04 0n b0be0et0tw0we0ee0en between 7 percent. Medical Billing Revenue Management Pre... to Post Collections EHR & More Are inefficiencies and delays hindering your practice? professions also share core social and ethical values. As outlined in Fight Club: Doctors vs. Lawyers A Peace Plan Grounded in Self-Interest, which appeared in the June issue of Chicago Medicine, the professions just don t know each other. Attorney-author Andrew J. McClurg, JD, highlighted a survey of medical, law and business students that showed they think remarkably alike except on cost containment issues that affect their own profession. Nevertheless, the different groups strongly agreed that liabilit reform would be effective at reducing healthcare costs. McClurg points out that lack of trust in lawyers and doctors can result in legal action when patients and clients are disappointed with unanticipated results. On a broader policy level, he says, the lack of trust can cause the public to be more willing to support government regulation that hurts both professions. In light of mounting evidence that public confidence is declining for all professions, doctors and lawyers have a joint stake in working together to build and sustain trust and respect in the professions as a whole. The Medical Society supports McClurg s proposals for new forms of interaction and communication between attorneys and physicians to repair their relationship. Working with the ABA s Health Law Section, Chicago Medicine has published a legal section in each issue featuring attorney-written articles. We are also exploring a joint committee for both organizations to work together, as well as a legal referral service for doctors, including blogs and forums. This partnership paves the way for future educational programming, and is proof the Society continues to reinvent member programs and services on behalf of Chicago s physicians. Together we will meet the changes and challenges ahead ext with RMK... it's as simple as 123! July

18 Legislative advocacy ISMS Protects Physicians from Bad Bills Dodging the reimbursement razor by ISMS President William N. Werner, MD, MPH Medicaid Cuts Everybody is going to get a haircut. No one will get scalped that s the basic concept. When those words were uttered by our Governor in reference to Medicaid back in February we knew we had our work cut out for us. With Illinois Medicaid reimbursements, doctors have been sporting crew cuts for several years. Fortunately, Illinois physicians have dodged the reimbursement razor this time around. We didn t just get lucky when we dodged significant cuts in the $2.7 billion package of reductions that passed in May. It took tremendous effort from our legislative advocacy team to avoid acrossthe-board cuts. In addition to our people on the ground in Springfield, we had two factors working on our side to prevent the cuts: our already-low reimbursement rates, and looming changes to federal law. Being 40th in the nation isn t a good track record, but in this case it helped make our case that further lowering of reimbursements isn t feasible. Current rates don t fully cover the cost of care and some physicians are forced to limit their Medicaid patient population. An additional cut would only exacerbate the problem. The Affordable Care Act (ACA) also provided a leg up. During Illinois Medicaid reform negotiations (and at the time of this writing), the U.S. Supreme Court had not yet ruled on the constitutionality of the ACA. As part of this law, the federal government plans to fill Medicaid s gap with Medicare primary care rates in ; the law requires states to pay for primary care at least at the same level they did in This also made cutting physician fees here difficult. Of course, even these difficulties would have been easy to overcome for a General Assembly frantic to fill a $2.7 billion hole in Illinois Medicaid budget if it weren t for our strong advocacy. ISMS made tremendous efforts to press our case to lawmakers and explain why physician rates must be protected from further reductions. Medicaid is still a deeply troubled program, and some of the other policies included in the reform package could further burden physicians or hinder patient 16 Chicago Medicine July care. But the fact is, ISMS protected our interests when others could not. I won t call us winners in the Medicaid debate, as the Associated Press did, because many of the problems we ve identified with the Medicaid program remain. We re concerned that some of the other policies included in the reform package could further burden physicians or hinder patient care. Nor is it good to be wedged against policy where our patients are deemed losers, as many have suggested, because cuts will limit certain treatment options. Rich Miller, a syndicated columnist who covers Springfield issues, wrote a feature highlighting ISMS position of strength in the Medicaid debate when problems arose related to the cigarette tax. We supported the tax, but several lawmakers were being pressured to vote against it by powerful national anti-tax groups. At the end of the day, as the column stated: in Illinois, some things still trump national party interests. The Medical Society is one of those things. Health Care Liens ISMS advocacy is also strong on issues that don t make the papers. This year, the Illinois Trial Lawyers Association introduced a bill related to medical liens, a topic too dry for mainstream media that nevertheless can be bread and butter for many physicians. Essentially, the trial lawyers wanted to further limit physician billing rights. This bill would have taken away the right of the physician to pursue collection of reasonable charges for services provided to an injured person while increasing the amount plaintiffs and their lawyers can recover. It would have limited the amount of any lien to a reimbursement rate established by the injured party s health insurance company, even though the insurance company may not be responsible for payment of the claim. The bill would have made other reductions to lien amounts and even would have required a lien holder to pay a share of the injured party s attorney s fees and litigation expenses. In the end, however, through the tireless efforts of ISMS legislative advocacy team, we were able to remove all the harmful provisions of this bill. Physician Licensure Fees An ISMS-backed measure to extend Illinois Medical Practice Act was again introduced in the spring session. For the past several years we have been forced to fight each year to extend the Medical Practice Act, without which there would be no rules for what medicine is and who can practice it. Our goal is to pass a ten-year extension; each time there is a vote on the act, it is an opportunity for lawmakers to tinker with what defines medicine in Illinois. Unfortunately, some lawmakers crave such tinkering, and our bill was amended to a one-year extension. It passed out of the Senate, but stalled in the House. The extension will require action in the fall. Renewing the Medical Practice Act should be simple, but the Quinn Administration and several members of the General Assembly want to double physician licensure fees; separate legislation was even introduced in the Illinois House this year for just that purpose. Proponents argue that the rates haven t changed in 25 years, physicians in other states pay more and even some professionals here pay higher fees. The purpose of licensure fees is to pay for the licensure and discipline process. However, over the past several years the state has swept more than $8 million from the funds we pay and used them for other purposes. As long as the legislature uses the Medical Disciplinary Fund as its piggy bank, smashing it every time they need more money, we will be opposed to any increase in physician licensure fees. Earlier this spring, Dr. Wayne Polek testified to this effect before a House committee in his capacity as ISMS President. Thanks to his testimony and our advocacy, the bill to double physician licensure fees failed. The fight is not over, however we expect to deal with this issue once again when lawmakers return in the fall. (The Chicago Medical Society works through the Illinois State Medical Society to introduce and influence legislation at the state level. The process begins in the CMS Governing Council, a launching pad for resolutions that may be further debated at the ISMS House of Delegates and the American Medical Association.)

19 member benefits service of the month cms career center and Job board in THis CHAnging practice landscape, where 49% of residents and 65% of established physicians are joining hospital-owned practices, the Chicago Medical Society can expand your employment reach. Whether you are looking for a new position, or ready to take the next step in your career, our online Career and Job Center connects medical professionals like you with employers nationwide. Our participation in a national network allows active and passive job seekers to post and view hundreds of positions at leading institutions and groups, with always fresh content. This resource is for physicians, physician assistants, nurse practitioners and administrative medical staff. The site s services include career coaching, advice on preparing a CV and interviewing, and a content library. When you open an account, you can store your CV and search-alerts in one place and sign up for special alerts when a new job matches your search criteria. Easy-to-use tools make searches more organized and efficient. Recruiters also enjoy access to qualified candidates across a range of specialties and locations. We help large health systems, private practices, government agencies, and academic medical centers to find physicians and other key staff with the right credentials and experience. With the click of a button, the site brings job seekers and ers together, saving them time and money, and recruitexpanding their reach. We urge you to get the most of your membership by using the Society s Career and Job Center. If you have suggestions or feedback, be sure to drop us a line. Please go to for additional information or call the Society The Cms online Career Center and Job Board is a resource for physicians, nurse practitioners and administrative medical staff. We reward loyalty. We applaud dedication. We believe doctors deserve more than a little gratitude. We do what no other insurer does. We proudly present the Tribute Plan. We honor years spent practicing good medicine. We salute a great career. We give a standing ovation. We are your biggest fans. We are The Doctors Company. You deserve more than a little gratitude for a career spent practicing good medicine. That s why The Doctors Company created the Tribute Plan. This one-of-a-kind benefit provides our long-term members with a significant financial reward when they leave medicine. How significant? Think new car. Or maybe vacation home. Now that s a fitting tribute. To learn more about our medical professional liability program, including the Tribute Plan, call our Chicago office at (800) or visit Tribute Plan projections are not a forecast of future events or a guarantee of future balance amounts. For additional details, see 3761_IL_ChicagoMed_June2012.indd 1 July /18/12 9:34 AM17

20 member benefits A New Twist on Stroke Treatment Society s mini-internship program teams with primary stroke centers by Christine Fouts Ald. Jason Ervin (28th Ward) left, tells Rush Neurologist Dr. Neelum Aggarwal, and Dr. Howard Axe, CMS President, how he would have recognized his father s recent stroke symptoms if he had known then what he learned during his tour of Mount Sinai s Primary Stoke Center. Mount Sinai and Swedish Covenant Hospitals were the sites for two recent CMS-sponsored mini-internships that educate legislators on issues in medicine. The Chicago Medical Society s Mini-internship Program expanded its scope, launching tours of Cook County s regional Primary Stroke Centers on June 4-5. The tours complement the Society s partnership in a citywide campaign to promote the benefits of these specialized stroke treatment centers (see story on page 20). The first facility visits brought Ald. Jason Ervin (28th Ward) to Mount Sinai Hospital, and Ald. Patrick J. O Connor (40th Ward) and State Rep. Greg Harris (D-13) to Swedish Covenant Hospital. Legislators heard about risk factors, warning signs, treatment and rehabilitation of stroke patients. Primary stroke centers provide care efficiently and effectively, with fewer complications, reducing morbidity and mortality, the stroke team said. Patients are more likely to receive acute stroke therapies, like tpa, although the overall goal is to deliver standardized care in a seamless environment that reduces hospitalization. Because of the infrastructure and organization required to triage and treat patients, stroke experts at Swedish Covenant say it takes a village to establish and maintain a primary stroke center that follows the recommendations of the American Stroke Association s Task Force on the Development of Stroke Symptoms. The stroke center team includes specialists in neurology and neurosurgery, emergency medicine, 18 Chicago Medicine July 201 2

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